Average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Laurels Of Charlottesville during CMS and state inspections, most recent first.
Facility staff did not post the grievance procedure or identify the grievance officer in any nursing units or the lobby, and neither residents nor staff knew how to file a grievance or who the grievance officer was. A grievance filed by a resident's responsible person was not resolved within the facility's required timeframe, instead being addressed only at the time of the resident's discharge.
Multiple residents did not receive care as ordered, including missed or incorrect medication doses, failure to monitor and document vital signs and weights as prescribed, and lack of timely physician notification regarding significant changes. These deficiencies were identified through interviews, record reviews, and direct observation, with staff acknowledging the lapses and no further information provided by facility leadership.
Failure to Provide and Post Resident Rights Information: Residents were not given an annual review of resident rights and facility rules, and rights were not posted in accessible locations. During a unit tour, rights were found only on one unit and posted too high for wheelchair users, while other units and common areas had none posted. Residents and the activity director stated the yearly review was not being done, and several residents confirmed the rights had not been reviewed with them this year.
Abuse prevention screening was incomplete for multiple employee files, with missing reference checks, unverified nursing licenses, and absent criminal background checks. In a separate incident, a CNA was reported by a resident and two nearby residents for cursing, yelling, and speaking in a demeaning manner during care, but the facility’s investigation concluded the event was not substantiated and treated it as a customer service issue despite statements describing verbal abuse.
Care plans were not kept accurate for multiple residents. One resident who was dependent for bed mobility still had an ADL plan listing partial assistance, another resident with end-stage dementia still had a call-light intervention despite being total care and unable to use it, a third resident’s plan listed dementia even though it was not a diagnosis, and a fourth resident’s plan still included a discontinued supplement and did not reflect a current daily weight order with notification parameters.
A resident with multiple insulin orders for DM had repeated delays in receiving Basaglar, Humalog sliding scale, Humalog 16-unit doses, and weekly Trulicity. The resident said morning insulin was often given late and an afternoon dose had been held because the morning dose was administered too late. The DON confirmed meds should be given within an hour of the scheduled time but had no explanation for the repeated delays.
Medication labeling and storage were not consistently maintained. An opened insulin pen on one unit had no open date, an unopened insulin vial that should have been refrigerated was stored in a med cart, and an opened multi-dose Tuberculin vial on another unit had no open date. In addition, a resident's prescribed glaucoma eye drops were left unsecured at the bedside instead of being stored in a locked location.
Meals were not served at appetizing temperatures on one unit. During a test tray, breakfast items were lukewarm or cold, including eggs, sausage, a cinnamon bun, and coffee, and the dietary manager acknowledged the food could be warmer and the eggs were bland. Residents reported that meals were often cold and tasteless, and council minutes documented repeated complaints about cold food, overcooked items, and hot plates that were not warm. One resident stated the food was always cold and that menu choices and condiments were often unavailable.
Improper Food Storage, Labeling, and Sanitary Handling: Staff failed to label opened food items in the kitchen, wore no hair net or beard guard while handling food, and stored dirty bowls in a clean bowl holder. The dishwasher was leaking, the freezer was not reading properly and ice cream had thawed, and opened med pass containers in nourishment rooms were not dated or timed, including one with an old open date.
Failure to educate and offer COVID-19 vaccines to multiple residents was identified during record review. Four residents were not up to date on COVID immunizations, and two had signed consent forms for the booster, but there was no evidence the vaccine was administered. The IP confirmed the findings and stated the facility checks immunization status through the state registry and offers COVID and pneumonia vaccines, but the reviewed residents had not received the COVID booster or documented education.
Facility staff failed to accurately complete the MDS for a resident with multiple diagnoses, including a sacral pressure ulcer that was present and being treated upon admission. The MDS did not reflect the presence of the pressure ulcer, despite clinical documentation and ongoing wound care, due to an oversight by the RN MDS coordinator.
Staff failed to administer medications within the required timeframe for a resident with diabetes, repeatedly giving insulin and other medications outside the one-hour window of scheduled times. In a separate incident, an LPN left medications with a resident and walked away without confirming ingestion, which was later discovered by the resident’s family. Additionally, staff did not document a thorough assessment of a pressure ulcer for another resident, omitting details such as size and appearance until a week after admission. These actions did not meet professional standards of nursing practice.
Facility staff did not provide required ADL assistance to three residents, including failure to assist with shaving, inadequate meal setup and feeding support for a resident with upper extremity impairments, and lack of timely response to call bells resulting in two residents remaining in wheelchairs for hours and one calling 911 for help. Documentation and staff interviews confirmed these lapses in care.
A resident with multiple chronic conditions had physician orders for daily wound care, but nursing staff failed to document wound care or the resident's refusals on the TAR for two shifts. Interviews confirmed that the resident refused treatment, but the assigned nurses did not record the refusals as required, resulting in incomplete medical records.
Two certified nursing assistants did not receive the required training for caring for residents with cognitive impairments, as confirmed by staff interviews and a review of training records. The staff development coordinator was responsible for ensuring training, but documentation showed that not all staff completed the necessary dementia care education.
Staff failed to honor resident rights by entering resident rooms without knocking or asking permission on the 200 unit. A CNA entered multiple rooms without knocking, and another CNA entered a resident’s room three times during an interview without knocking. Residents also reported in council that some staff knock before entering and some do not.
A facility failed to give written notice before changing the rooms of two residents. One resident said she was moved to another unit for LTC without prior written notice, and the social service director could not provide evidence that notice had been given. Another resident was moved from a private room to a semi-private room after being placed on contact isolation and noted to have a bedbug in her bedding, but she said she received no written notice; the room change form was completed later by the SW.
A resident council meeting was held in the dining room with a sign posted, but staff entered the area during the meeting and the discussion was paused until they left. The resident council president said staff come in and out when meetings are held in the dining room for more space. Facility policy stated the council must be allowed to meet without interference and be provided space and privacy with no interruptions, if possible.
Failure to Protect Resident from Verbal Abuse: A resident reported that a CNA cursed at him, told him to shut up, and spoke to him in a degrading manner when he asked for help. Two nearby residents heard the exchange and described it as loud, frightening, and unprofessional. The facility interviewed the resident, the CNA, and the two witnesses, but still documented the allegation as not substantiated even though the DON later acknowledged the behavior was abusive and neglectful.
Failure to develop a baseline care plan within 48 hours of admission for a resident with CHF, muscle weakness, Afib, CKD stage 3A, AKI, and osteoarthritis. The record showed the care plan focus areas and interventions were dated outside the required timeframe, and the RN care plan coordinator stated that diagnoses generate the baseline care plan but had no explanation for the delay.
Facility staff failed to provide ordered respiratory care for two residents. One resident’s O2 concentrator was running above the ordered 2 L rate, and an LPN later confirmed the order and adjusted it. Another resident’s nebulizer mask was left open to air instead of being stored in a clean bag for infection control, despite an active order for nebulizer treatments and a care plan for respiratory issues.
Failure to honor a resident’s food preferences occurred when a resident who requested double meat and double vegetables was served a breakfast tray with only two slices of bacon instead of the ordered double portion. The resident reported that menu selections were often not followed and that the food was cold. The dietary manager confirmed the tray did not meet the resident’s ordered preference, and the resident’s record documented a goal to honor food preferences.
A resident with a physician order for fortified foods due to weight loss was twice observed at lunch without the ordered fortified items. The resident received a PB&J sandwich with dessert and a drink, while fortified foods such as mashed potatoes and ice cream were available in the kitchen. The dietary manager confirmed what counted as fortified foods, and the resident's order was documented on the daily meal ticket.
A facility failed to implement its infection prevention and control program for a resident on contact isolation for C. diff. Surveyors observed the resident’s door posted with enhanced barrier precautions signage even though the matrix identified transmission-based precautions and the clinical record contained an active order for contact isolation related to C. diff, along with an active vancomycin taper order. The IP RN stated the contact precautions order was supposed to be discontinued and said she was not aware of loose stools documented in the record.
Failure to Offer and Document Flu and Pneumococcal Vaccinations: The facility did not provide education or offer the flu vaccine to one resident who was eligible during flu season, and there was no consent or declination in the chart. For another resident, pneumococcal immunization documentation was inaccurate, with a consent form appearing to indicate acceptance but entered as a refusal, and the resident’s pneumonia vaccines were not up to date.
A facility staff member failed to follow physician's orders for tube feeding flushes for a resident. The LPN did not perform the required water flushes before and between medications, nor before the bolus feeding, as observed during a survey. The LPN admitted to misreading the orders, and the deficiency was confirmed through clinical record review and facility policy. The issue was discussed with the facility's administration and clinical staff, resulting in a deficiency citation, F693.
Failure to Post Grievance Procedure and Timely Resolve Resident Grievance
Penalty
Summary
Facility staff failed to resolve a resident grievance in a timely manner, did not post the identification of the grievance officer, and did not display the grievance procedure in the facility. During a tour of multiple nursing units and the lobby, surveyors observed that there was no information posted regarding the grievance officer or the process for filing a grievance. At a resident council meeting attended by 15 residents, none were aware of who the grievance officer was or how to file a grievance. Residents expressed that they were unaware of grievance forms and did not know if a grievance officer existed at the facility. Interviews with staff, including the activity director and social service director, revealed that they also did not know who the grievance officer was. The administrator later stated that they were currently acting as the grievance officer due to staff turnover, and confirmed that there was no posting about the grievance officer or procedure. A review of facility documentation showed that a grievance filed by a resident's responsible person listed five concerns and was not resolved until the resident's discharge, which was nearly three weeks after the grievance was filed. The facility's policy requires that concerns be discussed with the interdisciplinary team the day after receipt and that investigations be completed within 5-7 business days. The delay in resolving the grievance and the lack of posted information about the grievance process and officer were confirmed during the survey, and no additional information was provided by facility leadership prior to the exit interview.
Failure to Follow Physician Orders and Medication Administration Protocols
Penalty
Summary
The facility failed to provide treatment and care in accordance with physician orders, resident preferences, and goals for seven residents. In one case, a resident with multiple diagnoses including cellulitis, amputation, and MRSA did not receive a scheduled dose of Cefazolin antibiotic because the medication was not administered as ordered, despite the medication being available in the STAT box. The nurse on duty did not utilize the available medication, and there was no documentation explaining the omission. Another resident was administered an incorrect dose of Baclofen, receiving 10 mg in the morning instead of the ordered 5 mg. The LPN responsible for the medication pass took the dose from the supply card labeled for bedtime, rather than the correct morning dose, even though the correct medication was available. Additionally, a resident with orders for vital signs every shift did not have these assessments completed on two separate day shifts, with no explanation documented in the clinical record. Further deficiencies included failure to administer insulin as ordered and within the standard time frame, with missed or delayed doses and lack of documentation or physician notification regarding omissions. Several residents with orders for daily weights and physician notification for significant weight changes did not have weights recorded on multiple days, and in some cases, significant weight changes were not communicated to the physician as required. These failures were confirmed through interviews, clinical record reviews, and facility documentation, with no additional information provided by the facility prior to the survey's conclusion.
Failure to Provide and Post Resident Rights Information
Penalty
Summary
The facility failed to appropriately inform residents, both orally and in writing, of their rights and all rules and regulations governing resident conduct and responsibilities during their stay, and resident rights were not visibly posted for easy access by all residents. During a tour of nursing units one, two, and three, resident rights were observed posted only on unit two, above the water fountain and at a height that was not accessible to wheelchair-bound residents; units one and three had no resident rights posted, and they were not posted in common areas or the lobby. Residents in council meeting stated that no one reviews resident rights yearly, and the activity director stated she does not go over resident rights in resident council meetings and does not do a yearly review with residents. Interviews with residents confirmed that the yearly review had not occurred. Resident #82 stated the rights were posted too high to read from a wheelchair. The social services director stated resident rights were reviewed on admission by the admissions director, but she was not reviewing them yearly. Facility documents titled Services and Payment Sources were provided for five residents, but only one form had the activity director's signature indicating completion. Four residents interviewed stated the rights had not been reviewed with them this year, including one resident who said they were not reviewed on the date documented and another who said they were not reviewed in March as recorded. Facility documentation also showed that some residents had been given facility rules on admission, but the yearly review and accessible posting of resident rights were not completed as described.
Abuse Prevention Screening and Abuse Investigation Failures
Penalty
Summary
The facility failed to follow its abuse prevention policies during pre-employment screening for 13 of 25 employee records reviewed. Twelve records had no reference checks, two nursing licenses had not been verified before employment, and two records had no criminal background checks completed before or within 30 days of hire. The facility’s abuse prevention policy required screening for history of abuse, neglect, exploitation, misappropriation of property, or mistreatment, including attempts to obtain information from prior employers, verification with licensing boards and registries, and background checks per state guidelines. The facility also failed to identify abuse in its investigation of an allegation involving a CNA and a resident. The resident reported that the CNA cursed at him, told him to shut up, and spoke to him in a demeaning manner when he asked for help. Two residents across the hall reported hearing the interaction and described the CNA yelling, cursing, and speaking to the resident in a non-professional way. The resident stated the interaction made him feel cheap, hurt his feelings, and made him feel like a fool, and he said the CNA had been rough with him before when turning him and hit his head against the bed railing. The facility’s incident synopsis concluded that the allegation of abuse was not substantiated and characterized the event as a customer service issue, despite statements from the resident and two other residents describing verbal abuse. During interviews, the administrator defined abuse as verbal, physical, mental, or anything that could cause anguish, and stated that abuse could exist if it had the potential to cause anguish. The DON acknowledged that the resident had reported verbal aggression and that statements from adjacent residents described the CNA as unprofessional, while the nurse consultant agreed the conduct was abusive and neglectful.
Care plans not updated to match resident status and orders
Penalty
Summary
The facility failed to review and revise comprehensive care plans for four residents. For one resident with bilateral above-knee amputation, acute respiratory failure, peripheral vascular disease, and diabetes, the most recent MDS showed the resident was dependent for bed mobility and unable to self-position in bed, yet the ADL care plan still listed supervision and partial assistance for bed mobility. Staff observations during the survey showed aides and the wound care LPN assisting to turn the resident in bed for wound care, and the RN/MDS coordinator stated someone should have caught that the resident was dependent on bed mobility and revised the care plan. For another resident with end-stage Alzheimer’s disease, dementia, neurocognitive disorder, and adult failure to thrive, the MDS showed severe cognitive impairment and dependence for all ADLs and mobility. Survey observations showed the resident in bed with a call bell within reach, but the resident was nonverbal and did not attempt to reach for it when asked. The resident’s responsible party raised concern about the resident’s inability to use the call bell, and staff interviews with an OT, CNA, and RN/MDS coordinator indicated the resident was total care, unable to follow directions, and unable to use the call bell, yet the ADL care plan still directed staff to encourage the resident to use the bell/call light for assistance. A third resident’s care plan included dementia even though dementia was not listed in the diagnosis, progress notes, or MDS, and the MDS showed a BIMS score of 13 with no cognitive impairment. For a fourth resident, the care plan was not updated to reflect a physician order for daily weights with notification parameters for weight gain, and it still listed a Magic Cup supplement that had been discontinued over a year earlier. The resident’s care plan also continued to include an older intervention for monthly weights rather than the current daily weight order, and the RN care plan coordinator confirmed the care plan did not list the daily weights and still noted the discontinued supplement.
Insulin Not Administered Timely
Penalty
Summary
The facility failed to ensure that one resident, who had multiple insulin orders for diabetes management, received insulin within the expected time frame. The resident reported that morning insulin was frequently not given until late morning and stated that an afternoon dose had recently been held because the morning dose had been administered too late. The resident also expressed concern that insulin should not be given too close together and that medications should not be administered at lunchtime. Clinical record review showed orders for Basaglar 34 units twice daily, Humalog sliding scale before meals and at bedtime, Humalog 16 units three times daily, and weekly Trulicity. The MAR scheduled Basaglar for 9 a.m. and 9 p.m., Humalog sliding scale for 6:30 a.m., 11:30 a.m., 4:30 p.m., and 9 p.m., Humalog 16 units for 9 a.m., 1 p.m., and 5 p.m., and Trulicity for 4:30 p.m. on Fridays. The DON provided a Location of Administration report showing numerous occasions when insulin was not administered within one hour of the scheduled time. Examples included Basaglar doses given after 11:00 a.m. on multiple days, Humalog sliding scale doses given well after the scheduled meal-related times, including doses administered after lunch had already occurred, and fifteen instances in July 2025 when the 16-unit Humalog doses were given outside the one-hour window, some by as much as two hours and 38 minutes. Trulicity was also administered more than five hours after the scheduled time. During interview, the DON confirmed medications are to be given within an hour of the scheduled time and had no explanation for why the resident's insulin was not administered within that standard.
Medication Labeling and Storage Deficiencies
Penalty
Summary
Drugs and biologicals were not consistently labeled and stored in accordance with accepted professional principles. On unit 2, an opened glargine insulin pen was found in the medication cart with no date documenting when it had been opened, and an unopened vial of Admelog insulin that was labeled to refrigerate until opened was also stored in the cart instead of the refrigerator. An LPN stated insulin pens were supposed to be dated when opened and was unsure why the unopened vial was not refrigerated. The RN unit manager stated unopened insulin should have been refrigerated and that all insulin pens and vials were supposed to be dated when opened so they could be discarded appropriately. On unit 1, an opened multi-dose vial of Tuberculin was found in the medication refrigerator with no open date written on the label. The vial was labeled to discard after 28 days, but there was no documentation showing when it had been opened. The LPN who was present stated the Tuberculin should have an open date on the bottle or package. Facility guidance presented during the survey stated Tuberculin tests should be stored in the refrigerator and dated when opened. For one resident, two prescription eye drops were left at the bedside on a table rather than secured. The resident stated the drops were being used from home and that the nurse had given them to keep. The bottles were labeled with the resident's name and were dispensed by the facility's contracted pharmacy. The assigned LPN later retrieved the drops and stated residents are not permitted to keep medications in their room, while the unit manager stated medications are stored in the medication cart and should not be kept at the bedside. The resident's record showed orders for Brimonidine Tartrate ophthalmic solution and Dorzolamide HCl-Timolol Maleate ophthalmic solution for glaucoma.
Meals Served Cold and Unappetizing
Penalty
Summary
Food and drink were not maintained at palatable, attractive, and safe appetizing temperatures for residents on nursing unit two. During a test tray observation on 7/23/25, the breakfast meal arrived at 8:09 a.m. and was served at 8:19 a.m. in a Styrofoam container. The eggs were bland and lukewarm at 130 degrees, sausage links were lukewarm at 121 degrees, the cinnamon bun was lukewarm, hard on the edges, and bland at 105 degrees, and the coffee was lukewarm at 125 degrees. When interviewed shortly after the observation, the dietary manager stated the food could be warmer and that the eggs were lukewarm and bland tasting. Resident interviews and facility records reflected ongoing concerns about food quality and temperature. Several residents on unit two stated that meals were often cold and had no taste, and the resident council minutes documented repeated complaints over several months about cold food, vegetables and meat being overcooked or burnt, and hot plates not being warm. One resident stated the food was always cold, that menu choices were often unavailable, and that meals were poorly prepared with missing condiments. When that resident was observed receiving breakfast, she reported all of the food was cold, and the dietary manager agreed to prepare a new plate.
Improper Food Storage, Labeling, and Sanitary Handling
Penalty
Summary
The facility failed to store, label, and distribute food in a sanitary manner in the main kitchen and nourishment rooms. During a tour of the main kitchen, whole hot dogs and red onions were found in the walk-in refrigerator in covered containers with no date or time indicating when they were opened. A container of tuna had a use-by date of 07/16/2025, and a ham salad sandwich in the reach-in refrigerator was labeled 07/17/2025 and was removed by the Dietary Manager for disposal. The Dietary Manager was also observed inside the walk-in freezer removing food items for discarding while not wearing a hair net, and a dietary aide with visible facial hair below the chin was observed in the kitchen without a beard guard. Additional kitchen observations showed several bowls in the clean bowl holder that were wet and had dried food particles on them, despite being stored as clean bowls. The Dietary Manager stated the bowls were supposed to be clean and removed nine bowls that were clearly wet and contaminated. The dishwasher was leaking and had gone down two days earlier, and disposable food containers and plastic utensils were being used to serve food. During the same tour, the reach-in freezer was not registering a temperature on the outside thermometer reader, and the ice cream stored inside had thawed and was soft. The dietary cook stated he had checked the freezer temperature that morning, and the temperature log showed an evening shift temperature recorded as -6 degrees at 10:45 a.m., which the Dietary Manager later marked out as inaccurate. On the nursing units, nourishment rooms also contained improperly stored med pass containers. On Unit two, four opened med pass containers were not labeled with a date and time. On Unit three, three med pass containers were not labeled with a date or time, and one container had an open date of 5/26/25. An LPN stated the containers should be dated and are only good for four hours on the med cart before being thrown away. Another LPN stated the dated container had been opened awhile and would be discarded. Facility documents reviewed stated that leftover foods should be covered, dated, and labeled, that refrigerator and freezer temperatures must be maintained at specified levels, and that food brought in from family would not be stored in the Dietary department.
Failure to Educate and Offer COVID-19 Vaccines
Penalty
Summary
The facility failed to provide education and offer the COVID-19 vaccine to four of five residents reviewed for immunizations. During a clinical record review, Resident #17 had a most recent COVID vaccine dose given prior to admission, but there was no indication in the record that the resident had been educated about immunizations or offered the COVID booster. Resident #13 had a most recent COVID immunization dated 2/26/21, and although a consent form dated 10/14/24 showed the resident's representative consented to the booster, there was no evidence that it had been administered. Resident #2 was admitted to the facility and was not up to date on COVID immunizations, with the most recent COVID immunization documented as 4/24/21. There was no evidence that Resident #2 received education or was offered the COVID vaccine. Resident #14 was also not up to date with COVID vaccination, and a signed consent form dated 10/14/24 indicated the resident wanted the booster vaccine, but there was no indication that the 2024-2025 COVID booster had been given. The facility's infection preventionist reviewed the charts and confirmed these findings. The infection preventionist stated that current immunizations help keep residents protected and decrease infection control issues, and explained that the facility checks immunizations through the Virginia Immunization Information System. She also stated the facility offers pneumonia and COVID vaccines and had recently been informed about using a third-party vendor for vaccine clinics, but the four reviewed residents had not received the immunizations. The facility policy required education for new residents and representatives, signed consent or declination, and use of the approved fact sheet, and CDC guidance reviewed by surveyors stated that the 2024-2025 COVID vaccine is recommended for most adults, especially those age 65 and older and those living in LTC facilities.
Inaccurate MDS Assessment for Pressure Ulcer
Penalty
Summary
Facility staff failed to complete an accurate Minimum Data Set (MDS) assessment for one resident who was admitted with multiple diagnoses, including cerebrovascular accident, hemiplegia, atrial fibrillation, aphasia, cognitive communication deficit, diabetes, dysphagia with gastrostomy, dementia, hypertension, and a pressure ulcer. The resident's clinical record documented the presence of a stage 2 sacral pressure ulcer upon admission, with corresponding physician orders and daily wound care treatments recorded in the treatment administration records. Despite this documentation, the admission MDS completed for the resident did not indicate the presence of any unhealed pressure ulcers or injuries in Section M0210, omitting the sacral pressure ulcer that was present and being treated. During an interview, the RN MDS coordinator acknowledged that the pressure ulcer should have been coded on the MDS as present upon admission and attributed the omission to an oversight. The deficiency was confirmed through staff interview and clinical record review, and was discussed with facility leadership during the survey.
Failure to Follow Professional Standards in Medication Administration and Wound Assessment
Penalty
Summary
Facility staff failed to adhere to professional standards of nursing practice in several instances involving three residents. For one resident with multiple insulin orders, staff did not administer insulin and other medications within the required one-hour window of the scheduled time on numerous occasions. This included delays of up to several hours for both scheduled and sliding scale insulin doses, as well as a weekly injectable medication. The resident expressed concern about the timing of her insulin administration, noting that doses were sometimes given so late that subsequent doses had to be skipped or were administered too close together. The Director of Nursing confirmed that medications are expected to be given within an hour of the scheduled time, and facility documentation corroborated the repeated delays. In another case, a nurse provided a resident with medication and left the room without ensuring the medication was ingested. The incident was discovered when the resident’s family found medications left on the bed. The nurse involved acknowledged walking away while the resident was taking the medication and was subsequently reprimanded. There was no documentation in the clinical record or progress notes regarding this incident, and the unit manager confirmed the event had occurred and that staff are not permitted to leave medications with residents unsupervised. For a third resident, staff failed to document a thorough assessment of a pressure ulcer upon admission and during the first week of the resident’s stay. The initial nursing assessment noted the presence of a stage 2 pressure ulcer but did not include any description of the wound’s size, appearance, or characteristics. Daily treatment was provided and documented, but no descriptive assessments were recorded until a week later when a wound nurse practitioner performed a detailed evaluation. Both the unit manager and the DON acknowledged that nurses are expected to document wound appearance and characteristics, and facility policy requires such documentation for residents with wounds.
Failure to Provide ADL Assistance to Dependent Residents
Penalty
Summary
Facility staff failed to provide necessary assistance with activities of daily living (ADLs) for three residents who required varying levels of support. One resident, who required moderate to maximum assistance with all self-care, was not shaved by staff during his stay, despite repeated requests from his spouse. Documentation and interviews confirmed that staff were hesitant to shave him, and the issue was only addressed on the day of discharge, after a grievance was filed. Another resident, who had significant upper extremity impairments and required setup or clean-up assistance for eating, did not receive the necessary support during a meal. The resident was found upset, unable to access or eat her breakfast due to missing utensils, unopened food items, and the absence of milk for her cereal. The dietary manager confirmed the deficiencies in meal setup and food quality, and the resident's clinical record supported her need for assistance. A third resident, who required extensive two-person assistance for bed mobility, transfers, and toileting, reported not receiving care for over two and a half hours despite repeated use of the call bell. The resident and her roommate remained in their wheelchairs all day, resulting in pain and distress, and the resident's son ultimately called 911 for help. Documentation for the relevant shift was blank, and staff interviews confirmed that lack of documentation indicated care was not provided. No grievance was filed for this incident, and facility leadership was unaware of the event until informed by surveyors.
Failure to Document Wound Care and Resident Refusals
Penalty
Summary
A deficiency was identified when the facility failed to ensure complete and accurate documentation of wound care for one resident. The resident, who had a history of cellulitis, right toe amputation, congestive heart failure, MRSA, and diabetes, was admitted with an order for daily and evening wound care and dressing changes to the right foot. Review of the Treatment Administration Record (TAR) revealed that documentation was missing for the day shift on 3/16/25 and the evening shift on 3/17/25, with no indication that the dressing changes were completed or refused. Interviews with nursing staff confirmed that the resident had refused the dressing changes on the dates in question. However, the assigned nurses did not document the refusals on the TAR or in a progress note, as required. One nurse acknowledged forgetting to document the refusal due to being busy, and it was noted that the resident often refused dressing changes. The lack of documentation was confirmed by the unit manager and discussed with facility leadership.
Failure to Provide Required Dementia Care Training to Staff
Penalty
Summary
Facility staff failed to ensure that all staff received the required training related to the care of residents with cognitive impairments, including dementia. During interviews and a review of facility documentation, it was determined that two out of five certified nursing assistants reviewed did not complete the necessary training for caring for cognitively impaired residents. The staff development coordinator was responsible for providing training and orientation, and the facility's annual training schedule was supposed to include dementia care. However, training records showed that two certified nursing assistants had not received this required training, as confirmed by the staff member overseeing training and the documentation reviewed.
Failure to Knock Before Entering Resident Rooms
Penalty
Summary
The facility failed to uphold resident rights and to knock before entering residents’ rooms on the 200 unit. On 7/22/2025 at 8:37 a.m., a CNA entered rooms 201, 203, and 206 without knocking or requesting permission to enter. When questioned, the CNA stated she should knock before entering a resident’s room and said there was no reason she had not knocked, adding that she was just busy and usually does knock. Later that day, during a resident council meeting, residents reported that some staff knock before entering and some do not. The facility also failed to knock before entering Resident #22’s room; on 7/22/2025 at 3:39 p.m., while the surveyor was interviewing the resident, a CNA entered the room three times without knocking. When questioned, the CNA said she was passing ice and stated she normally does knock and is always to knock before entering a resident’s room.
Failure to Provide Written Notice for Room Changes
Penalty
Summary
The facility failed to provide written notice before changing the room of two residents, affecting Resident #17 and Resident #38. Resident #17 reported that she was moved from one unit to another unit to remain in LTC and was not notified in writing before the move. The social service director stated that residents are supposed to be notified in writing prior to a room change, but no written notice for Resident #17 was provided during the survey. The clinical record showed a social worker note indicating the resident’s mother was contacted about the room change and that the resident would be moved to a LTC bed placement, and the care plan noted the resident required 24-hour care/LTC placement related to dementia and that the family/legal decision maker had accepted the plan for her to remain in the facility. Resident #38 stated that her room had been changed and she was unsure why, and she said she was not given anything in writing about the change. The record showed she was admitted to a private room and was moved on 7/14/25 to a semi-private room; progress notes stated she was on contact isolation in a private room and that she had a bedbug in her bedding, with a physician note indicating she was to be moved and isolated. A Notice of Room Change form was not completed until 7/22/25 by the social worker, who stated she did not know about the room change until then. The facility policy and resident rights document both stated that written notice of a room or roommate change is required, and the administrator and DON were informed of the concern at the end of the survey.
Resident Council Meeting Lacked Privacy
Penalty
Summary
The facility failed to provide a private area without staff interference for a resident council meeting. On 7/22/25 at 3:00 p.m., the resident council met in the dining room area with a sign posted outside the door, dietary staff asked to keep the kitchen doors closed, and staff asked not to enter until the meeting was completed. During the meeting, three staff members entered the dining room and stood in the back talking with staff in the kitchen, and the meeting was paused until they left. Later that day, the resident council president stated that when meetings are held in the dining room for more space, staff come in and out as they want. Facility documentation reviewed the next day stated that the facility must allow resident councils to organize without interference and provide space and privacy for meetings with full auditory and visual privacy and no interruptions, if possible.
Failure to Protect Resident from Verbal Abuse
Penalty
Summary
The facility failed to protect one resident’s right to be free from verbal abuse by staff. Resident #43 reported that a CNA came into his room early in the morning, cursed at him, told him to shut up, and used degrading language when he asked for help. He stated the interaction made him feel cheap, hurt his feelings, and made him feel like a fool. He also reported that the same CNA had previously been rough with him and struck his head against the bed rail while turning him, but he did not report that earlier event at the time. Two residents in rooms across the hall reported hearing the exchange. One resident stated the CNA loudly cursed at the resident, told him to shut up, and slammed the door, describing the event as frightening and saying it woke her and her roommate from sleep. The other resident also reported being awakened by the yelling and hearing the CNA curse at the resident and tell him to shut up. Facility statements collected during the investigation included accounts from the resident, the two adjacent residents, and the CNA, all describing a loud confrontation with profanity and disrespectful language directed toward the resident. The facility’s investigation synopsis concluded the allegation of abuse was not substantiated, although the CNA was not continued in employment. The administrator stated the resident did not feel abused and that the facility viewed the matter as rough care and a customer service issue. The DON later acknowledged that the resident had been verbally aggressive with the CNA and that other residents heard her yelling and speaking to the resident in a non-professional way, but the facility still documented the abuse allegation as not substantiated. The facility abuse policy defined verbal abuse as conduct that causes or has the potential to cause humiliation, intimidation, fear, shame, or degradation.
Failure to Develop Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for Resident #31. The resident was admitted with diagnoses including acute on chronic diastolic heart failure, muscle weakness, paroxysmal atrial fibrillation, chronic kidney disease stage 3A, acute kidney failure, and osteoarthritis of the knee. A review of the electronic record showed that the care plan focus areas and interventions were all dated 7/21/25, which was outside the 48-hour requirement for a baseline care plan. During interview, the RN care plan coordinator stated that entering diagnoses generates the baseline care plan and that staff then personalize it, and she acknowledged that the care plan is important because it drives the resident’s care. When the delay in developing the baseline care plan for Resident #31 was discussed, the RN had no explanation.
Oxygen and Nebulizer Equipment Not Managed per Orders
Penalty
Summary
Facility staff failed to administer oxygen at the physician-ordered rate for one resident. Resident #35 had an active order for oxygen at 2 liters via nasal cannula as needed for shortness of breath or pulse-ox less than 90%, and the resident’s diagnoses included dependence on supplemental oxygen, COPD, dysphagia, CKD3b, and Afib. During observation, the resident’s oxygen concentrator was running at just above 3 liters and the cannula was on the floor. The resident stated she wore oxygen daily but was unsure of the rate. A later observation again showed the concentrator running above 3 liters, and an LPN reviewed the record, confirmed the 2-liter order, and adjusted the concentrator to 2 liters. Facility staff also failed to store respiratory equipment in a manner to prevent contamination for another resident. Resident #22 had an active order for Ipratropium-Albuterol inhalation solution twice daily for SOB/wheezing and a care plan addressing respiratory complications related to COPD, bilateral PE, morbid obesity, anxiety, and cough. During observation, the resident’s nebulizer was on the bedside table and the mask was left open to air. The resident reported using the nebulizer twice daily and having a persistent cough, and an LPN confirmed the nebulizer should be stored in a bag for infection control but observed that it was not stored that way and had been left from the prior day.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to serve meals in accordance with a resident’s stated food preferences for Resident #22. During an interview, the resident reported that on Tuesdays residents are given a menu to select choices for the following week, but said the selections were not honored because staff frequently stated they were out of items. The resident also complained about the food and said staff did not pay attention to what they were doing. On 7/23/2025, the resident was observed in bed and served breakfast consisting of a small portion of eggs, two slices of bacon, and a cinnamon roll. The resident stated the food was cold. The meal ticket identified special diets of double meat portions and double vegetables, with a handwritten entry for egg, 2x bacon, and cinnamon roll. The dietary manager confirmed that double bacon would mean four slices, acknowledged the resident did not receive the requested double portion of bacon, and agreed the tray was not prepared as ordered. The resident’s clinical record included a nutritional evaluation noting a CCD diet, regular texture, thin liquids, and a desire for double meat and double vegetable portions, with a nutrition goal to honor food preferences. The facility policy stated that food preferences would be identified on tray tickets to ensure residents receive appropriate food items.
Failure to Provide Ordered Fortified Foods
Penalty
Summary
The facility failed to provide a therapeutic diet as ordered for Resident #59, who had a physician's order for fortified foods due to weight loss. During a lunchtime meal observation on 7/21/25, the resident was served a peanut butter and jelly sandwich, chocolate cake, and tea, but was not served the fortified foods listed on the meal ticket. A second lunchtime observation on 7/22/25 showed the resident again receiving a peanut butter and jelly sandwich, apple crisp, and juice without any fortified food, even though mashed potatoes and ice cream were available in the kitchen as fortified foods. The dietary manager stated that fortified foods included items such as ice cream, mashed potatoes, and puddings. Review of the resident's clinical record confirmed the physician's order for fortified foods and that the order appeared on the daily meal ticket printed by the kitchen. Facility documentation titled Diet Orders stated that the facility would adhere to therapeutic diet parameters during food preparation and when dispensing condiments. The concerns were discussed with the administrator, DON, ADON, and regional clinical director during an end-of-day meeting, and no additional information was provided before exit.
Infection Prevention and Control Program Not Implemented for Resident on C. diff Precautions
Penalty
Summary
The facility failed to implement its infection prevention and control program for one resident who was on contact isolation for C. difficile. During a tour of nursing unit two, the resident’s door signage was observed to indicate enhanced barrier precautions, while the facility matrix identified the resident as being on transmission-based precautions. The clinical record contained a physician order for contact isolation related to C. diff, and a later observation again showed enhanced barrier precautions signage posted outside the resident’s door. On interview, the infection preventionist RN stated the resident should not have been on contact precautions because the order was supposed to be discontinued, and said the resident was not being treated for an active case of C. difficile. However, the clinical record review showed an active order for contact precautions related to C. diff and an active vancomycin taper order for C. diff. The infection preventionist also stated she was not aware of loose stools being charted in the clinical record. The administrator, DON, ADON, and regional clinical director were informed of the concerns at the end-of-day meeting.
Failure to Offer and Document Flu and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to provide education and offer influenza and pneumococcal vaccinations to two of five residents reviewed for immunizations. For one resident, the clinical record showed admission during the 2024/2025 flu season and a most recent influenza vaccine dose dated 3/8/23, but there was no evidence that the resident was educated about or offered the flu vaccine for that season, and the chart contained no consent or declination documentation. For another resident, the record showed a most recent readmission following hospitalization on 12/26/24 and a pneumococcal history of only PPSV23 on 10/20/2014. The immunization tab reflected a refusal of the pneumococcal vaccine, but the consent form had been marked declined with an error and initials, while the consent box was checked. The form was dated 6/28/23 but entered into the immunization tab as a refusal dated 7/12/23. During interview, the infection preventionist, who was also the RN assistant DON, reviewed the charts and confirmed that the first resident was eligible for the flu vaccine and that no documentation showed it was offered. The infection preventionist also confirmed the second resident’s pneumonia immunizations were not up to date and that the consent form appeared to indicate the resident wanted the vaccine but had been inaccurately recorded as a refusal. The facility’s policies and CDC adult immunization standards were reviewed with the administrator and DON, and no additional information was provided.
Failure to Follow Physician's Orders for Tube Feeding Flushes
Penalty
Summary
The facility staff failed to adhere to physician's orders regarding tube feeding flushes for a resident, identified as Resident #1 (R1), during a survey. The deficiency was observed when an LPN administered medications and a bolus tube feeding to R1 without performing the required water flushes as per the physician's orders. Specifically, the LPN did not flush the peg tube with 15cc of water before and between medications, nor did they flush with 50cc of water prior to the bolus feeding, although a 120cc flush was administered after the bolus feeding. Upon interview, the LPN acknowledged the oversight, stating that they misread the orders. A review of R1's clinical records confirmed the physician's orders for specific water flushes before and after medication administration and bolus feedings. The facility's policy on medication administration via enteral routes also outlined the necessity of verifying medication orders and performing water flushes between medications. The deficiency was discussed with the facility's administration and clinical staff, and it was substantiated with a deficiency citation, F693.
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What surveyors actually found near you
We read the 78 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Charlottesville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Our Lady Of Peace Inc | 0.4 mi | ★★★★★ | 15 | 0 |
| Monroe Health & Rehab Center | 0.8 mi | ★★★★★ | 20 | 0 |
| Charlottesville Health & Rehabilitation Center | 1.1 mi | ★★★★★ | 7 | 0 |
| Colonnades Health Care Center | 1.1 mi | ★★★★★ | 0 | 0 |
| Cedars Healthcare Center | 1.5 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.